Trinity Grove

631 Junction Creek Drive
Wilmington, NC, 28412
9104423000
CCN: 345554
3
Overall
2
Health
5
Staffing
3
Quality
ChainLUTHERAN SERVICES CAROLINAS
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
LUTHERAN SERVICES FOR THE AGING, INC.5% OR GREATER DIRECT OWNERSHIP INTEREST100%
SMITH, KESHACORPORATE DIRECTORNOT APPLICABLE
NICKERSON, KIRBYCORPORATE OFFICERNOT APPLICABLE
MADDRY, KARENCORPORATE OFFICERNOT APPLICABLE
GOINS, TEDOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PARRISH, JAMESOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
SMITH, KESHAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
SUTTON-SURAK, AUDREYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LUTHERAN HOME WILMINGTON PROPERTY, INCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LSA MANAGEMENT, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LUTHERAN SERVICES FOR THE AGING, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (3)
DateTypeAmount
2025-09-18Fine$100K
2024-10-10Fine$21K
2024-08-05Fine$9K
Health Deficiencies (16)
2025-09-18 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
C
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
G
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
B
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
E
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
2024-10-10 · Health
D
F810 · Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
G
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024-08-05 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
K
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
K
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023-07-13 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F811 · Nutrition and Dietary Deficiencies
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-05-09 · Health
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
4.36
3.68
RN Hrs/Resident/Day
0.96
0.54
LPN Hrs/Resident/Day
0.70
0.81
CNA Hrs/Resident/Day
2.69
2.33
PT Hrs/Resident/Day
0.08
0.12
Data as of 2026-03-01